State, Local, Tribal Gov't

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0579-XXXX. The time required to complete this information collection is estimated to
average 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
NATIONAL VETERINARY SERVICES LABORATORIES
1920 DAYTON AVENUE, AMES, IA 50010
515-337-7266

HPAI H5N1MILK SUBMISSION FORM

1. SUBMITTER INFORMATION
NAME (Including Business Name)

2. OWNER INFORMATION

EMAIL ADDRESS (For results reports)

OWNER CITY

STATE

OF

PREMISES ID

PHONE NUMBER

4. COLLECTED BY

NATIONAL ACCREDITATION NUMBER

FAX NUMBER

5. DATE COLLECTED:

6. REFERRAL NUMBER

7. PURPOSE OF SUBMISSION (“X” Must select one, but ONLY one option)
Program (Herd Status) Testing

PAGE

3. LOCATION OF ANIMALS
COUNTY
STATE

OWNER NAME

MAILING ADDRESS (Street, City, State, ZIP Code)

OMB Approved
0579-XXXX
Exp. XX/XXXX

Healthy Animal/Herd
(Non-Program)

Sick Animal/Herd

Research

Animal Movement

8. TOTAL NUMBER OF SAMPLES
SUBMITTED

9. SAMPLE INFORMATION
SAMPLE NO.

IDENTIFICATION

IF SINGLE ANIMAL SAMPLE:
BREED

SAMPLE NO.

AGE

IDENTIFICATION

IF SINGLE ANIMAL SAMPLE:
BREED

SAMPLE NO.

AGE

IDENTIFICATION

IF SINGLE ANIMAL SAMPLE:
BREED

SAMPLE NO.

AGE

IDENTIFICATION

IF SINGLE ANIMAL SAMPLE:
BREED

SAMPLE NO.

AGE

IDENTIFICATION

IF SINGLE ANIMAL SAMPLE:
BREED

AGE

SAMPLE GROUP

SAMPLE SOURCE

COMMENTS:

☐ SICK
☐ FRESH
☐ HEALTHY
☐ NEW ARRIVAL

☐ SINGLE
☐ STRING
☐ BULK
☐ TANKER

NO OF COWS REPRESENTED
IN SAMPLE:

SAMPLE GROUP

SAMPLE SOURCE

COMMENTS:

☐ SICK
☐ FRESH
☐ HEALTHY
☐ NEW ARRIVAL

☐ SINGLE
☐ STRING
☐ BULK
☐ TANKER

NO OF COWS REPRESENTED
IN SAMPLE:

SAMPLE GROUP

SAMPLE SOURCE

COMMENTS:

☐ SICK
☐ FRESH
☐ HEALTHY
☐ NEW ARRIVAL

☐ SINGLE
☐ STRING
☐ BULK
☐ TANKER

NO OF COWS REPRESENTED
IN SAMPLE:

SAMPLE GROUP

SAMPLE SOURCE

COMMENTS:

☐ SICK
☐ FRESH
☐ HEALTHY
☐ NEW ARRIVAL

☐ SINGLE
☐ STRING
☐ BULK
☐ TANKER

NO OF COWS REPRESENTED
IN SAMPLE:

SAMPLE GROUP

SAMPLE SOURCE

COMMENTS:

☐ SICK
☐ FRESH
☐ HEALTHY
☐ NEW ARRIVAL

☐ SINGLE
☐ STRING
☐ BULK
☐ TANKER

NO OF COWS REPRESENTED
IN SAMPLE:

10: REQUIRED FOR PROGRAM (Herd Status): SIGNATURE OF COLLECTOR AND DATE: I certify that samples were collected according to the herd plan.

11. ADDITIONAL DATA (History, clinical signs, remarks, special instructions. Use additional sheets, if necessary).

JUN 2024

LABORATORY USE ONLY

TBD 2022

VS FORM XX INSTRUCTIONS

ALL information must be printed legibly or typed. Use a
separate form for each owner. At the minimum, complete all
fields designated in these instructions as required. Contact
the Receiving Department of the laboratory to which you are
sending specimens with specific documentation or shipping
questions.
If including more than one page, include the page number of
total pages submitted (e.g., 1 of 3).
1. SUBMITTER CONTACT INFORMATION

“REQUIRED”

Enter the submitter’s business name/affiliation; the name of
the individual submitter is optional if test results are returned
to a general business email. Enter an email address to
which APHIS can return test results. Multiple email
addresses are permissible. Provide a complete mailing
address. If email is not available, test reports may be
mailed, but this will delay delivery of results and may incur a
fee. Repeat submitters are encouraged to be consistent with
the submitter contact information that is provided, as the
NVSL keeps a master record

Research – Tests conducted for the purpose of supporting a
research project conducted by staff or field personnel of VS
or by other laboratories, institutions, or agencies.
8. TOTAL NUMBER OF SAMPLES SUBMITTED
“REQUIRED”
Enter the total number of samples submitted from this farm.
9. SAMPLE INFORMATION
Collect samples in vials provided by the NAHLN laboratory
or the local District VS office. Use provided bar codes and
place one barcode on the tube of milk and one on the VS-XX
form under Sample No.
Enter the identification information. If the sample is from an
individual animal, use the official ID. If the sample is an
aggregate sample, use appropriate identifying information
that allows for repeated sampling if necessary. Fill out breed
and age for individual samples only.
Sample Group applies to both individual sample collections
and aggregate samples. Select the most appropriate box.

Enter the complete name of the owner, the city and the twoletter abbreviation of the State in which the owner resides.
Ensure the animal owner is identified here and not the
property manager or veterinarian.

Sample Source: Select the most appropriate box. Individual
samples must include milk from all lactating quarters from
the cow. Select the most appropriate box for aggregate
samples and use the comment area to clarify if needed.
Include collection dates in the comment area if they vary
between samples. Ensure to include the number of cows
representing the aggregate sample.

3. LOCATION OF THE ANIMALS

10. SIGNATURE OF COLLECTOR AND DATE

2. OWNER INFORMATION

“REQUIRED”

“REQUIRED”

Specify the county, parish, or other designated location of
the animals and the two-letter State abbreviation. Premises
ID is required. Contact your state veterinary office to obtain.

Required for Program (Herd Status) samples: Ensure the
sample collector signs the form verifying the samples were
collected according to the herd plan.

4. COLLECTED BY
Enter the complete name of the person collecting the
specimen(s).
5. DATE COLLECTED
Enter the date on which specimens were collected. Use the
format DD/MM/YYYY. If samples were collected on different
days, write the sample collection date in the comments
section for each sample.
7. PURPOSE OF SUBMISSION

“REQUIRED”

Definitions of Diagnostic Case Categories are as follows:
Program (Herd Status) testing – Tests conducted under the
H5N1 Herd Status program. The collector must sign the
bottom of the form certifying samples were collected
according to the approved herd plan.
Heathy Animal/Herd – Tests conducted when animals or the
herd does not clinical signs of a disease (above normal herd
dynamics) and chooses not to participate in the official Herd
Status Program.
Sick Animal/Herd – Tests conducted when animals or the
herd have clinical signs of a disease.
Animal Movement – Tests conducted for the purpose of
qualifying live animals or poultry for interstate movement.

11. ADDITIONAL DATA
Enter all pertinent information about the animals and
premises that can assist the lab.
• Provide detail on collections as needed
• Include any information that did not fit into its designated
space elsewhere on the form.
• Include any special (non-standard) instructions for test
report delivery